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Medicine Record Form
Written by HealthyPlace.com Staff Writer   
PDF Print E-mail
Feb 07, 2007 A +  A -  RESET  

For Keeping Track of Medications

Print this form. Write down the name of each medicine you take, the reason you take it, and how you take it, in the spaces below. Add new medicines when you get them. You can show the list to your health professionals. You may want to make copies of the blank form so you can use it again. This form was developed by the National Council on Patient Information and Education.

Name of medicine
Reason taken
Dosage
Time(s) of day
























Over - the - Counter Medicines (Check here if you use any of these)


Laxatives

Dietary Supplements / Herbals

Vitamins

Cold medicine

Aspirin/other pain,headache, or fever medicine

Cough medicine

Allergy relief medicine

Antacids

Sleeping pills

Others (names)

next: How to Talk About Your Medications

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Last Updated( Mar 09, 2009 )
reviewed by: Harry Croft, MD
Psychiatrist, HealthyPlace.com Medical Director
 

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